Healthcare Provider Details

I. General information

NPI: 1104929504
Provider Name (Legal Business Name): PRISMA COMMUNITY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 09/02/2025
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N. CENTRAL AVENUE SUITE 200
PHOENIX AZ
85004
US

IV. Provider business mailing address

1101 N CENTRAL AVE STE 200
PHOENIX AZ
85004-1844
US

V. Phone/Fax

Practice location:
  • Phone: 602-307-5330
  • Fax: 602-307-5021
Mailing address:
  • Phone: 602-347-0873
  • Fax: 602-246-1980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State

VIII. Authorized Official

Name: CASEY SIMON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 602-307-5330